Find synonyms Find exact match. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to Perfectil Psoriasis Bewertungen the content.

Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy. Most cases are not severe enough to affect general health and are treated in the outpatient setting. Rare life-threatening Perfectil Psoriasis Bewertungen can occur that require intensive inpatient management. This topic reviews the treatment of psoriatic skin disease.

The epidemiology, clinical manifestations, and diagnosis of psoriatic skin disease are discussed in detail separately, as are psoriatic arthritis and the management of psoriasis in pregnant women and special populations. See "Epidemiology, clinical manifestations, and diagnosis of psoriasis" and "Treatment of psoriatic arthritis" and "Pathogenesis of psoriatic arthritis" and "Clinical manifestations and diagnosis of psoriatic arthritis" and "Management of psoriasis in pregnancy" and "Treatment selection for moderate to severe plaque psoriasis in special populations".

Therefore, management of psoriasis involves addressing both psychosocial and physical aspects of the disease. Numerous topical and systemic therapies are available for the treatment of the cutaneous manifestations of psoriasis. Treatment modalities are chosen on the basis of disease severity, relevant comorbidities, patient preference including Perfectil Psoriasis Bewertungen and convenienceefficacy, and evaluation of individual patient response [ 1 ].

Although medication safety plays an important role in treatment selection, this must be balanced by the risk of undertreatment of psoriasis, leading to inadequate clinical improvement and patient dissatisfaction [ 2,3 ]. The clinician needs Perfectil Psoriasis Bewertungen be empathetic and spend adequate time with the patient. It may be helpful for the clinician to touch the patient when appropriate to communicate physically that the skin disorder is neither repulsive nor contagious.

Clinicians should lay out reasonable aims of treatment, making it clear to the patient that the primary goal of treatment is control of the disease. Although treatment can provide Perfectil Psoriasis Bewertungen with high degrees of disease improvement, there is no cure for psoriasis.

Educating the patient Perfectil Psoriasis Bewertungen psoriasis is important and referral to an organization such as the National Psoriasis Foundation www. Patients with limited skin disease may still have significant psychosocial disability [ 6 ]. However, even patients on systemic therapy will likely continue to need some topical agents.

Topical therapy may provide symptomatic relief, minimize required doses of systemic medications, and may even be psychologically cathartic for some patients. For purposes of treatment planning, patients may be grouped into mild-to-moderate and moderate-to-severe disease categories.

Limited, or mild-to-moderate, skin disease can often be managed with topical agents, while patients with moderate-to-severe disease may need phototherapy or systemic therapy.

Perfectil Psoriasis Bewertungen location of the disease and the presence of psoriatic arthritis also affect the choice of therapy.

Psoriasis of the hand, foot, or face can be debilitating functionally or socially and may deserve a more aggressive treatment approach. The treatment of psoriatic arthritis is discussed separately. See "Treatment of psoriatic arthritis". Moderate-to-severe psoriasis is typically defined as involvement of more than 5 to 10 percent of the body surface area the entire palmar surface, including fingers, of one hand is approximately 1 percent of the body surface area [ 7 ] or involvement of the face, palm or sole, or disease that is otherwise disabling.

Patients with more than 5 to 10 percent body surface area affected are generally candidates for phototherapy or systemic therapy, since application of topical agents to a large area is not usually practical or acceptable for most patients.

Attempts to treat extensive disease with topical agents are often met with failure, can add cost, and lead to frustration in the patient-clinician relationship.

There is ample evidence of efficacy of the newer systemic therapies "biologics" ; however, cost is a major consideration with these agents. Established therapies such as methotrexate and phototherapy continue to play a role in the management of moderate to severe plaque psoriasis. The management of patients with extensive or recalcitrant disease is a challenge even for experienced dermatologists.

However, the availability of biologic medications has reduced the challenge considerably. The concept that many patients with psoriasis in the United States do not receive sufficient treatment to control the disease is suggested by an analysis of surveys performed by the National Psoriasis Foundation between and [ 2 ].

Among the Perfectil Psoriasis Bewertungen respondents with psoriasis, 52 percent expressed dissatisfaction with their treatment. Many patients received no treatment, including 37 to 49 percent of respondents with mild psoriasis, 24 to 36 percent of respondents with moderate psoriasis, and 9 to 30 percent of respondents with severe psoriasis.

Further studies will be useful for clarifying the reasons for these observations and for determining the value of interventions to increase the accessibility of treatment. Widespread pustular disease requires aggressive treatment, which may include hospitalization. Therapeutic approaches to generalized pustular psoriasis and psoriatic arthritis are discussed separately.

Management" and "Treatment of psoriatic arthritis". Alternatives include vitamin D analogs, such as calcipotriene and calcitrioltar, Perfectil Psoriasis Bewertungen topical retinoids tazarotene. For facial or intertriginous areas, topical tacrolimus or pimecrolimus may be used as alternatives or as corticosteroid sparing agents, though improvement may not be as rapid.

Calcipotriene in combination with Class I topical corticosteroids is highly effective for short-term control. Calcipotriene alone can then be used continuously and the combination with Perfectil Psoriasis Bewertungen corticosteroids used intermittently on weekends for maintenance. A combination product containing calcipotriene and betamethasone dipropionate is available for this use.

With proper adherence, considerable improvement with topical therapies may be seen http://gl-dd.de/wie-psoriasis-an-den-haenden-entfernen.php as little as one week, though several weeks may be required to demonstrate full benefits. Because adherence to topical treatment can be a major hurdle, keeping the treatment regimen simple and using treatment vehicles that the patient finds acceptable is often beneficial [ 8 ].

These agents may be used alone or in combination with topical corticosteroids as corticosteroid sparing agents for long term maintenance therapy. Calcipotriene, tacrolimus, and pimecrolimus are more expensive options than topical corticosteroids. For many patients, lotion, solution, gel, foam, or spray vehicles are preferable to thicker creams or ointments. Topical corticosteroids are the primary topical agents used for psoriasis on the scalp [ 11 ].

Support for the use of these agents is evident in a systematic review of randomized trials that found that very potent or potent topical corticosteroids are more effective treatments for scalp psoriasis than topical vitamin D analogs [ 12 ]. Combining a corticosteroid and vitamin D analog may offer additional benefit; in the systematic review, combination treatment with a potent topical corticosteroid and a vitamin D analog appeared slightly more effective than potent topical corticosteroid monotherapy.

However, in clinical practice, complicating the treatment regimen with more than one topical product may reduce the likelihood of consistent adherence to the treatment continue reading. Thus, we usually prescribe a topical corticosteroid alone as initial therapy. Commercial betamethasone dipropionate-calcipotriene combination products are available, but are more expensive than most topical corticosteroid preparations.

See "Psoralen plus ultraviolet A PUVA photochemotherapy". Perfectil Psoriasis Bewertungen are limited on the use of systemic retinoids for localized pustular psoriasis. However, these drugs appear to be particularly effective in the treatment of pustular psoriasis, and we consider them first line therapy.

Acitretin is the retinoid that is used most often for this indication. Acitretin is a potent teratogen and should not be used in women who might become pregnant. Pregnancy is contraindicated for three years following acitretin therapy. The management of nail psoriasis is reviewed in detail separately. Based upon data from open-label or retrospective studies and case reports, a panel of experts suggested that patients with severe, unstable disease should be treated with cyclosporine or infliximab due to the rapid onset and high efficacy of these agents [ 13 ].

Patients with less acute disease can be treated with acitretin or methotrexate as this web page agents. The panel advised against the use of systemic glucocorticoids due to the perceived potential for these drugs to induce a flare of psoriasis upon withdrawal of therapy. Data are limited on the efficacy of biologic agents other than infliximab for the treatment of erythrodermic psoriasis. Etanercept was effective in an open-label study of 10 patients [ 14 ], and case reports have documented Perfectil Psoriasis Bewertungen treatment with adalimumab and ustekinumab [ 15,16 ].

Topical therapies, such as Perfectil Psoriasis Bewertungen topical corticosteroids, emollients, wet dressings, and oatmeal baths can be used in concordance with systemic treatment to manage symptoms [ 13 ].

Long-term maintenance therapy for psoriasis is required. Many agents used in the treatment of adult psoriasis have also been used for children [ 17 ]. However, high quality studies on the efficacy and safety of therapies for psoriasis in children are limited.

Guidelines for the Perfectil Psoriasis Bewertungen of children based upon the available evidence Perfectil Psoriasis Bewertungen been published [ 18 ]. See "Treatment selection for moderate to severe plaque psoriasis in special populations" and "Management of psoriasis in pregnancy". Published guidelines for the treatment of psoriasis with topical therapies Perfectil Psoriasis Bewertungen available [ 19 ]. Keeping psoriatic skin soft and moist minimizes the symptoms of itching and tenderness.

Additionally, maintaining proper skin hydration can help prevent irritation and thus the potential for subsequent Koebnerization development of new psoriatic lesions at sites of trauma. Perfectil Psoriasis Bewertungen most effective are ointments such as petroleum jelly or thick creams, especially when applied immediately after a hydrating bath or shower. The mechanism of action of corticosteroids in psoriasis is not fully understood.

Corticosteroids exert antiinflammatory, antiproliferative, and immunosuppressive actions by affecting gene transcription. The inherent potency of a topical corticosteroid is frequently reported using a I to VII scale based on vasoconstrictive assays table 1.

Although ointments are sometimes thought to be inherently more effective because Perfectil Psoriasis Bewertungen their occlusive properties, this is not uniformly correct. To minimize adverse effects and maximize compliance, the site of application needs to here considered in choosing the appropriately potent corticosteroid:.

The typical regimen consists of twice daily application of topical corticosteroids. Most patients will show a rapid decrease in inflammation with such therapy, but complete normalization of skin or lasting Perfectil Psoriasis Bewertungen is unpredictable.

Topical corticosteroids generally can be continued as long as the patient has thick active lesions. Skin atrophy from topical corticosteroids usually is not a problem unless the medication is continuously applied after the skin has returned to normal thickness.

Once clinical improvement occurs, the frequency of application should be reduced [ 19 ]. For patients in whom lesions recur quickly, Perfectil Psoriasis Bewertungen corticosteroids can be applied intermittently such as on weekends only to maintain Perfectil Psoriasis Bewertungen. The addition of non-corticosteroid topical treatments can also facilitate the avoidance of long-term daily topical corticosteroids.

The risks of cutaneous and systemic side effects associated with chronic topical corticosteroid use are increased with high potency formulations. Data support Perfectil Psoriasis Bewertungen the continuous application of Bananen Psoriasis-Behandlungen I topical corticosteroids to two to four weeks; thus, close clinician supervision should be employed if longer treatment durations are required table 1 [ 19 ].

Data are Perfectil Psoriasis Bewertungen clear regarding treatment durations for less potent topical corticosteroids. Side effects of topical corticosteroids, including the potential for suppression of the hypothalamic axis, are discussed separately.

See "Pharmacologic use of glucocorticoids" and "General principles of dermatologic therapy and topical corticosteroid use". The cost of topical corticosteroids varies widely. The price of a 60 Perfectil Psoriasis Bewertungen tube of a potent corticosteroid brand name product can be hundreds of dollars. There are generic preparations in each potency class that have reduced the cost somewhat, though generic prices in the United States are rising [ 21 ].

Different formulations have been developed in an effort to enhance the delivery of topical corticosteroids. Betamethasone valerate in a foam had superior efficacy for scalp psoriasis and was preferred by patients when compared with betamethasone valerate lotion [ 22 ]. Perfectil Psoriasis Bewertungen foam becomes a liquid on contact with skin and is also well tolerated by patients with trunk and extremity psoriasis [ 23 ]. A clobetasol propionate spray is also available; like foams, sprays are easy to apply to large areas [ 24 ].

The main advantage of these newer preparations is likely greater patient acceptance, which may translate into greater adherence; the main disadvantage is cost. Although topical vitamin D analogs are effective as monotherapy for some patients, a systematic review found that combination therapy with a topical corticosteroid is more effective than either treatment alone [ 25 ].

Untilcalcipotriene was the only topical vitamin D analog available in the United States. Calcipotriene is obtainable as a cream, solution, ointment, or foam, or as a combination ointment, suspension, or foam with betamethasone dipropionate. Topical calcitriol ointment has been prescribed in Europe for years, and is now available in the United States.

When compared with calcipotriene, calcitriol appears to induce less irritation in sensitive areas of the skin eg, skin folds [ 26 ]. The precise mechanism is not clear, but a major effect is the hypoproliferative effect on keratinocytes [ 27 ].

An immune modulating effect has been postulated for calcipotriene, but has Perfectil Psoriasis Bewertungen been shown to be significant in psoriasis to date [ 28 ]. Only potent topical corticosteroids appeared to have comparable efficacy at eight weeks.

Skin irritation is the main adverse event associated with calcipotriene. Combined use of calcipotriene and superpotent corticosteroids has demonstrated increased clinical response and tolerance in clinical trials compared with either agent used alone [ ]. One regimen employed daily use of both calcipotriene ointment and halobetasol ointment for two weeks, followed by weekend use of the halobetasol ointment and weekday use of calcipotriene [ 30 ].

This regimen produced six-month remission maintenance in 76 percent compared with 40 percent with weekend halobetasol alone. Perfectil Psoriasis Bewertungen similar regimen with calcipotriene ointment and clobetasol propionate foam also appears to be effective [ 33 ]. In addition, a randomized trial found that a preparation that combines calcipotriene with betamethasone dipropionate 0.

Patients who use topical corticosteroids in combination with calcipotriene must be monitored for adverse effects as with corticosteroid monotherapy. Thus, topical calcipotriene may be used as an alternative or adjunct to topical corticosteroid therapy. It is Perfectil Psoriasis Bewertungen twice daily when used as monotherapy. No controlled trials guide how best to use topical corticosteroids in conjunction with calcipotriene.

Once daily use of each Perfectil Psoriasis Bewertungen be adequate. Acidic products can inactivate topical calcipotriene, and some topical corticosteroids may be acidic. A reasonable approach to combination therapy is to have patients Perfectil Psoriasis Bewertungen topical calcipotriene and topical corticosteroids each once daily at different times of day.

Other than skin irritation, side effects of topical calcipotriene are usually minimal; the risk of hypercalcemia is low when the Ear Psoriasis is used appropriately [ 35 ]. However, topical calcipotriene is more expensive than many generic potent corticosteroids. In addition, calcitriol inhibits T-cell proliferation and other inflammatory mediators [ 36 ].

At the end of the study periods up to eight weeks In a systematic review, calcipotriene and calcitriol were equally effective [ 25 ]. However, on sensitive areas of the skin, calcitriol appears to be less irritating than calcipotriene. Perilesional erythema, perilesional edema, Perfectil Psoriasis Bewertungen stinging or burning sensations were significantly lower in the areas treated with calcitriol. A week open-label study of the safety of calcitriol ointment did not reveal an adverse effect on calcium homeostasis [ 38 ].

Similar to calcipotriene, calcitriol ointment is more expensive than many generic potent topical corticosteroids. The drug is applied twice daily. The precise mechanism of action of tar is not known; it has an apparent antiproliferative effect.

Tar can be helpful as an adjunct to topical corticosteroids. Tar products are available without a prescription in the form of shampoos, creams, Perfectil Psoriasis Bewertungen, ointments, and oils. Newer products include a solution and a Perfectil Psoriasis Bewertungen. Some patients may prefer the less messy formulations.

Tar can also be compounded into creams and ointments. Topical tar preparations, including shampoos, creams, and other preparations, can be used once daily.

Patients should be warned that tar products have the potential to stain hair, skin, and clothing. It may help to use them at night and wear inexpensive night clothes eg, old pajamas as they tend to be messy. Patients may also find the odor of tar products unpleasant. For shampoos, the emphasis should be on making sure the product reaches the scalp. Tar shampoo should be left in place for 5 to 10 minutes before rinsing it out. Another study found that once daily administration of tazarotene gel, 0.

Absorption of tazarotene was minimal over the week course of the see more, suggesting that systemic toxicity is unlikely during long-term therapy. A small uncontrolled study of short Perfectil Psoriasis Bewertungen tazarotene found that a 20 minute application followed by washing appeared to be less irritating than traditional use, and seemed to have similar efficacy [ 43 ].

Irritation limits use of tazarotene by itself; the irritation is reduced by concomitant treatment with a topical corticosteroid [ 44 ]. Facial and intertriginous areas may be well suited to these treatments, which can allow patients to avoid chronic topical corticosteroid use:. Topical tacrolimus and pimecrolimus are generally well tolerated when used to this web page facial and intertriginous psoriasis [ 49,50 ].

However, corticosteroid therapy Perfectil Psoriasis Bewertungen be more effective, at least compared with pimecrolimus. This was suggested in a four-week randomized trial in 80 Perfectil Psoriasis Bewertungen with intertriginous psoriasis that compared various therapies applied once daily [ 51 ].

Inthe US Food and Drug Administration FDA Perfectil Psoriasis Bewertungen an alert about a possible link between topical tacrolimus and pimecrolimus and cases of lymphoma and skin cancer in children and adults [ 52 ], and in placed a "black box" warning on the prescribing information for these medications [ 53 ]. No definite causal relationship has been established; however, the FDA recommended that these agents only be used as second line agents for atopic dermatitis.

Subsequent studies have not, however, found evidence of an increased risk of Perfectil Psoriasis Bewertungen [ 54,55 ]. The mechanism of action of anthralin in psoriasis is not well understood, but may involve antiinflammatory effects and normalization of keratinocyte differentiation [ 19 ].

Skin irritation is an expected side effect of anthralin that can limit the use of this therapy. This side effect and the ability of anthralin to cause permanent red-brown stains on clothing and temporary staining of Perfectil Psoriasis Bewertungen have contributed to a decline in the use of anthralin therapy. In order to minimize irritation, anthralin treatment is usually prescribed as a short-contact regimen that is titrated according to patient tolerance.

For example, treatment may begin with concentrations as low as 0. Then, weekly, serial increases in the concentration of anthralin can be performed eg, 0. Subsequently, the application time is titrated up to 20 to 30 minutes as tolerated.

Application to surrounding unaffected skin should be avoided to minimize irritation. For patients with well-defined plaques, petrolatum or zinc oxide may be applied to the surrounding skin as a protectant prior to application. After the desired contact period has elapsed, anthralin should be washed off the treated area [ 19 ]. Benefit Perfectil Psoriasis Bewertungen anthralin therapy is often evident within the first few Perfectil Psoriasis Bewertungen of therapy.

When administered by patients in the outpatient setting, anthralin is less effective than topical vitamin D or potent topical corticosteroid therapy [ 25,60,61 ]. Perfectil Psoriasis Bewertungen an example, patients often notice improvement in skin lesions during the summer months.

In choosing UV therapy, consideration must be given to the potential for UV radiation to accelerate photodamage and increase the risk of cutaneous malignancy. Phototherapy and photochemotherapy require the supervision of a dermatologist trained in these treatment modalities. The American Academy of Dermatology has provided guidelines for the treatment of psoriasis with ultraviolet light [ 62 ].

Despite high efficacy and safety, the use of office-based phototherapy has declined in the United States because of administrative issues and the development of new systemic medications [ 63 ]. The mechanism of action of UVB is likely through its immunomodulatory effects [ 64 ].

Patients receive near-erythema-inducing doses of UVB at least three times weekly until remission is Perfectil Psoriasis Bewertungen, after which a maintenance regimen is usually recommended to prolong the remission.

Suberythemogenic doses of narrow band UVB are more effective than broadband UVB in clearing plaque psoriasis [ 65 ]. Apoptosis of T Perfectil Psoriasis Bewertungen is also more common with nm than with broadband UVB.

With oral PUVA, patients ingest the photosensitizing drug, 8-methoxypsoralen, followed within two hours by exposure to UVA; this sequence is performed three more info weekly in increasing doses until remission, then twice or once weekly as a maintenance dose.

With bath PUVA, the psoralen capsules are dissolved in water, and affected skin hands, feet, or total body is soaked for 15 to 30 minutes prior to UVA exposure. There are few data on the comparative efficacy of oral and bath PUVA for psoriasis. A small open randomized trial of 74 patients with moderate to severe psoriasis did not find a significant difference in efficacy between the two treatments [ 67 ].

Additional studies are necessary to confirm this finding. Some patients take Perfectil Psoriasis Bewertungen prior to coming into the office or clinic for PUVA. Increased photosensitivity is typically present starting one hour after an oral dose and resolves after eight hours.

Pre and post treatment photoprotection eg, hat, sunscreen, sun protective goggles are critical in preventing serious burn injury to the skin and eyes from being outside. Pretreatment emollients have long been thought to improve results with UVB. However, while thin oils do not impede UV penetration, emollient creams can actually inhibit the penetration of the UV and should not be applied before treatment [ 68 Perfectil Psoriasis Bewertungen. Gentle removal of plaques by bathing does help prior to UV exposure.

Uncertainty remains about the comparative efficacy of UVB phototherapy and PUVA photochemotherapy for plaque psoriasis. Randomized trials comparing the efficacy of Perfectil Psoriasis Bewertungen UVB to PUVA have yielded inconsistent findings [ 69 ]. The convenience of not needing to administer a psoralen prior to treatment is a favorable feature of UVB phototherapy. This option may be preferred by patients who are not in close proximity to an office-based phototherapy center, whose schedules do not permit frequent office visits, or for whom the costs of in-office treatment exceed those of a home phototherapy unit.

In contrast, a randomized trial of subjects found that narrowband UVB administered via home units was as safe and effective as office-based treatments [ 71 ]. Home phototherapy units that are equipped with electronic controls Perfectil Psoriasis Bewertungen allow only a prescribed number Perfectil Psoriasis Bewertungen treatments are available and may help to mitigate clinician concerns.

Commercial tanning beds can improve psoriasis and are occasionally used for patients without access to medical phototherapy [ 72,73 ]. However, data are limited on this mode of treatment, and clinicians and patients should be cognizant that there is significant variability in the UV output of tanning beds [ 74 ].

The laser allows treatment of only involved skin; thus, considerably higher doses of UVB can be administered to psoriatic plaques at a given treatment compared with traditional phototherapy. Uncontrolled trials suggest that laser therapy results in faster responses than conventional phototherapy [ 75,76 ].

As an example, one study of excimer laser therapy involved patients with stable mild to moderate plaque check this out, of whom 80 completed the entire protocol [ 75 ].

Side effects of laser therapy included erythema and blistering; these were generally well tolerated, and no patient discontinued therapy because of adverse effects. A common sequela of excimer laser therapy is the induction of UV-induced hyperpigmentation tanning in Perfectil Psoriasis Bewertungen areas, which can be cosmetically distressing for some patients. Hyperpigmentation resolves after the discontinuation of treatment.

Like nm UVB, the excimer laser represents a therapeutic advance toward specific wavelength therapies for psoriasis. While both the excimer Perfectil Psoriasis Bewertungen and narrow band UVB are approved for use in Perfectil Psoriasis Bewertungen, inconsistencies in third party coverage for these treatments limit their utilization.

Ongoing monitoring is indicated in patients who have received prolonged courses of PUVA. In general, phototherapy is contraindicated in patients with a history of melanoma or extensive nonmelanoma skin cancer. In an in vitro study, exposure of plasma to UVA led to a 30 to 50 percent decrease in the serum folate level within 60 minutes [ 77 ]. However, Perfectil Psoriasis Bewertungen deficiency secondary to UVA exposure has not been proven to occur in vivo.

In a small randomized trial of healthy subjects, no difference in serum folate levels was identified between subjects irradiated with UVA for six sessions and untreated subjects [ 78 ]. In addition, an observational study of 35 psoriasis patients found that narrow band UVB had no effect on serum folate levels after 18 treatment sessions [ 79 ].

Bathing in sea water Perfectil Psoriasis Bewertungen combination with sun exposure climatotherapy has also Perfectil Psoriasis Bewertungen used as a therapy for psoriasis, as has the use of salt water baths with artificial UV exposure balneophototherapy.

A large, open, randomized trial found that treatment with UVB after a saltwater bath had greater efficacy than UVB after a tap-water bath, and similar efficacy to bath Perfectil Psoriasis Bewertungen [ 80 ]. Although the raters of disease severity were intended to be blinded, treatment assignment was known to the raters in nearly 60 percent of cases. In per-protocol analyses, no difference was found between saltwater and tap-water baths, and bath PUVA was superior to UVB after a saltwater bath.

In andthe American Academy of Dermatology published guidelines for the Perfectil Psoriasis Bewertungen of psoriasis with systemic therapies [ 81,82 ].

Inan update to the Perfectil Psoriasis Bewertungen S3-Guidelines on the systemic treatment of psoriasis was published Perfectil Psoriasis Bewertungen 84 ]. Options for systemic therapy include immunosuppressive or immunomodulatory drugs such as methotrexatecyclosporineapremilast and biologic agents.

Systemic retinoids, which Perfectil Psoriasis Bewertungen psoriasis through effects on epidermal proliferation and differentiation as well as immunomodulation, are also used for the treatment of this condition [ 81 ]. The efficacies of the various systemic treatments for psoriasis were compared in a systematic review of randomized trials. Indirect comparisons of the proportion of patients in placebo-controlled trials who achieved at least 75 percent improvement in the Psoriasis Area and Severity Index PASI score after 8 to 16 weeks of treatment showed that the efficacy of infliximab within this time period was superior to etanerceptadalimumabustekinumab 45 mg dosealefacept, cyclosporineand methotrexate [ 85 ].

In addition, head-to-head trials included in the systematic review supported the superiority of infliximab and adalimumab over methotrexate therapy and the superiority of Perfectil Psoriasis Bewertungen over etanercept therapy. Although knowledge of the relative efficacies of systemic treatments for psoriasis is Perfectil Psoriasis Bewertungen, consideration of factors such as drug side effects, patient preference, Perfectil Psoriasis Bewertungen availability, and treatment cost eg, the high cost of biologic agents compared with conventional therapies also play an important role in treatment selection.

It is also effective for the treatment of psoriatic arthritis and psoriatic nail disease. Perfectil Psoriasis Bewertungen thoughts on the mechanism of action centered around the antiproliferative effects of methotrexate on DNA synthesis in epidermal cells; subsequent evidence supports the concept that it is the immunosuppressive effects of methotrexate on activated T-cells that controls psoriasis [ 87 ].

In one trial, patients with moderate to severe plaque psoriasis were randomized to receive oral methotrexate 7. After 16 weeks, the proportion of patients achieving a 75 percent improvement in the PASI score with methotrexate was more than that with placebo but less than with adalimumab 36, 19, and 80 percent, respectively. A placebo-controlled randomized trial evaluating subcutaneous Perfectil Psoriasis Bewertungen After 16 weeks, 37 of 91 patients 41 percent in the methotrexate group achieved 75 percent improvement in the PASI score compared with 3 of 29 patients 10 percent in the placebo group [ 86 ].

Methotrexate is usually administered in an intermittent low-dose regimen such as once weekly. Similar regimens are in use in patients with rheumatoid Perfectil Psoriasis Bewertungen. Administration can be oral, intravenous, intramuscular, or subcutaneous; the usual dose range is between 7.

Unlike cyclosporinewhich is generally used for only limited courses of treatment, methotrexate can be used for long-term therapy. Folic acid1 mg daily, protects against Perfectil Psoriasis Bewertungen of the common side effects seen with low-dose methotrexate such as stomatitis [ 89 ].

Folate does not appear to protect Perfectil Psoriasis Bewertungen pulmonary toxicity, Perfectil Psoriasis Bewertungen it is uncertain whether it protects against hepatic toxicity; monitoring for bone marrow suppression and hepatotoxicity are http://gl-dd.de/psoriasis-guttata-anfangsstadium.php during therapy.

Concurrent use of other medications Perfectil Psoriasis Bewertungen interfere with folic acid metabolism, Perfectil Psoriasis Bewertungen as sulfa antibiotics, can increase the toxicity of methotrexate. See "Major side effects of low-dose methotrexate".

For patients with one or more risk factors for hepatotoxicity from methotrexate Perfectil Psoriasis Bewertungen, use of go here different systemic drug should be considered.

Inthe AAD and the National Psoriasis Foundation updated this recommendation with monitoring guidelines that are dependent upon the presence or absence of risk factors for hepatotoxicity [ 81,91 ].

Risk factors for hepatotoxicity from methotrexate include [ 91 ]:. Patients without risk factors for hepatotoxicity should have liver chemistries Perfectil Psoriasis Bewertungen every one to three months. If five out of nine serum AST levels are elevated over the course of 12 months, or if the serum albumin level is decreased in the context Perfectil Psoriasis Bewertungen normal nutritional status Perfectil Psoriasis Bewertungen well-controlled psoriasis, a liver biopsy should be performed.

Liver biopsy should also be considered after a cumulative dose of 3. Once patients have reached this dose, options include proceeding with a liver biopsy, continuing to monitor without a liver biopsy, or discontinuing methotrexate therapy. In patients with risk factors for hepatotoxicity for whom the decision is made to proceed with methotrexateliver biopsies are considered earlier in the course of therapy.

Since a fair number of patients Ungarn Behandlung Psoriasis discontinue therapy within the first two to six months, it is reasonable to perform the biopsy after this time period. For patients who Perfectil Psoriasis Bewertungen methotrexate, liver biopsies should be considered after every 1 to 1.

Once patients have reached this dose, options include proceeding with a liver biopsy, discontinuing methotrexate, or consulting with a hepatologist for further evaluation. The retinoid of choice in psoriasis is acitretin. In a pilot study, 6 of 11 patients with psoriasis and HIV infection achieved good to excellent results with acitretin therapy, with four achieving complete clearing of their skin disease [ 92 ].

The usual dose range of acitretin is 25 mg every other day to 50 mg daily. Acitretin can be used in combination with UVB or PUVA therapy.

Used in this way, patients have higher response rates with better tolerance and less UV exposure [ 93,94 ]. Monitoring for hypertriglyceridemia and hepatotoxicity are required with retinoid therapy.

Common side effects include cheilitis and alopecia. Acitretin is teratogenic; it is only indicated in men and in women of non-reproductive potential. Pregnancy is contraindicated for three years after discontinuing the drug [ 95 ]. Improvement is generally observed within four weeks.

The use of cyclosporine in psoriasis is based upon multiple studies supporting its status as a highly and rapidly effective treatment [ 81, ]. As an example, a placebo-controlled randomized trial found that after eight weeks of treatment with 3, 5, or 7. All three regimens were superior to placebo, and patients who received the 5 mg dose were Anfangsstadien der Psoriasis auf dem Rücken likely to Perfectil Psoriasis Bewertungen dose alterations due to side effects or lack of efficacy.

A few randomized trials have compared the efficacy of cyclosporine and methotrexatePerfectil Psoriasis Bewertungen varying treatment regimens Perfectil Psoriasis Bewertungen providing different results. Close monitoring is required since renal toxicity and hypertension are common and often limit the long-term use of cyclosporine in patients with psoriasis.

See "Cyclosporine and tacrolimus nephrotoxicity". An investigational oral calcineurin inhibitor, ISA, was efficacious in randomized trials in patients with moderate to severe plaque Perfectil Psoriasis Bewertungen, and may have less nephrotoxicity than cyclosporine [ ]. The available biologics for psoriasis have visit web page short-term and long-term efficacy and favorable tolerability.

Biologic therapies available Perfectil Psoriasis Bewertungen the treatment of psoriasis in the United States include etanerceptinfliximabadalimumabustekinumabsecukinumaband ixekizumab. Network meta-analyses evaluating etanerceptinfliximabadalimumaband ustekinumab support the designation of infliximab as the most effective of these biologic agents for psoriasis [ ].

As an example, in the first network meta-analysis of randomized trials for biologic therapy designed to adjust for inter-trial variability in reference arm responses, infliximab was associated with the highest likelihood for achieving 75 percent improvement in Psoriasis Area and Severity Index PASI 75 scores [ ].

In addition, ustekinumab 45 or 90 mg dose and adalimumab yielded significantly higher PASI 75 rates than etanercept 25 or 50 mg dose. Of note, the network meta-analysis was based upon PASI 75 rates achieved after 8 to 16 weeks of Perfectil Psoriasis Bewertungen. Therefore, these results may not be applicable to longer periods of drug use.

A subsequent systematic review and meta-analysis that included the newer biologic Perfectil Psoriasis Bewertungen secukinumab and evaluated randomized trials with treatment durations of at least 24 weeks found evidence to support infliximab, secukinumab, and ustekinumab as the most effective long-term therapies [ ].

In a head-to-head trial, a week course of secukinumab was more effective than ustekinumab. Alefacept, another Perfectil Psoriasis Bewertungen agent, is no longer marketed. Itolizumab, a biologic agent marketed in India, is not available in the United States.

There is a concern that all tumor necrosis factor TNF -alpha inhibitors have the potential to activate latent infections such as tuberculosis, and increased rates of infection have been seen in patients with rheumatoid arthritis treated with etanerceptinfliximaband adalimumab. In addition, risk for herpes zoster may be increased in patients receiving biologic therapy in combination with methotrexate [ ].

An analysis of data from adults with psoriasis in a large registry of patients eligible to receive or receiving conventional systemic or biologic therapy Psoriasis Longitudinal Assessment and Registry [PSOLAR] found a higher risk of serious infections with adalimumab and infliximab compared with non- methotrexate and nonbiologic therapies [ Perfectil Psoriasis Bewertungen. Serious infection rates among patients treated with infliximab, adalimumab, etanerceptand ustekinumab were 2.

Among patients who had never received a biologic therapy or methotrexate Perfectil Psoriasis Bewertungen patients who had never received a biologic therapy but had received methotrexate, rates were 1. Data from another study of 12, patients in the PSOLAR registry provides some reassurance regarding the use of biologic therapy for psoriasis [ ].

Compared with treatment with non-biologic agents, biologic therapy did not appear to be a significant predictor of death, major adverse cardiovascular events MACEor malignancy. Patients were not randomized to the different treatment arms in the PSOLAR registry, and therefore selection bias could account for differences or lack of differences between groups.

It is approved by the US Food and Drug Administration FDA for adults with psoriatic arthritis and for patients age four years or older with chronic moderate to severe plaque psoriasis. Standard dosing for etanercept for adults is subcutaneous injection of 50 mg Perfectil Psoriasis Bewertungen weekly for the initial three click at this page of therapy, followed by a 50 mg injection once weekly for maintenance therapy.

After 12 weeks, there was at least a 75 percent improvement in a psoriasis area and severity index PASI score in 14, 34, 49, and 4 percent, respectively. After 24 weeks, such an improvement was seen in 25, 44, and 59 percent, respectively no patients received placebo for more than 12 weeks.

Etanercept was well tolerated with adverse events and infections occurring at similar rates in all four groups. A week randomized trial found similar benefits link subcutaneous etanercept 50 mg twice weekly, and that, compared with placebo, patients receiving etanercept had significant improvements in measures of fatigue and depression [ ].

Another randomized trial demonstrated efficacy in children and adolescents with moderate to severe plaque psoriasis [ ]. The long-term safety of etanercept for psoriasis is supported by a week study of etanercept 50 mg twice weekly [ ]. The formation of anti- etanercept antibodies has been reported to occur in 0 to 18 percent of patients treated with the drug for psoriasis [ ].

However, in contrast to antibodies against infliximab and adalimumab in patients treated for psoriasis with those agents, the formation Perfectil Psoriasis Bewertungen anti-etanercept antibodies does not appear to reduce treatment efficacy Perfectil Psoriasis Bewertungen ]. In addition, the findings of a systematic review suggest that the onset of action of infliximab is faster Perfectil Psoriasis Bewertungen other commercially available biologic agents [ ].

Infliximab was efficacious for psoriasis in a multicenter randomized trial in patients with severe plaque psoriasis. The duration of response appeared to be longer with the higher dose. More patients treated with infliximab had Perfectil Psoriasis Bewertungen adverse events 12 versus 0including four cases that the authors felt were reasonably related to treatment: At week 16, patients who did Perfectil Psoriasis Bewertungen achieve at least 50 percent improvement were able to switch to the alternative therapy.

In addition, patients who were transitioned from methotrexate to infliximab fared better than Perfectil Psoriasis Bewertungen who switched to methotrexate from infliximab; 73 versus 11 percent achieved 75 percent improvement in the PASI score. Maintenance therapy with infliximab also appears to be effective [ , ]. Infliximab was generally well tolerated.

In addition to experiencing better maintenance of response, there are some data that suggest that patients who receive continuous maintenance therapy with infliximab may be less likely to experience serious infusion-related reactions than patients who receive intermittent maintenance therapy.

In trials comparing the two modes of maintenance therapy, slightly higher rates of infusion-related reactions have Perfectil Psoriasis Bewertungen observed among recipients of intermittent maintenance therapy []. The reason for this Perfectil Psoriasis Bewertungen was unclear. Whether other regimens of intermittent maintenance therapy would be less likely to yield infusion reactions remains to Perfectil Psoriasis Bewertungen seen.

Studies in psoriasis, inflammatory bowel disease, and rheumatoid arthritis have suggested that the production of antibodies to infliximab may contribute to the loss of response to infliximab in some patients with these diseases [ finding Salben für das Gesicht von Psoriasis fatty, ]. Anti-infliximab antibodies have been reported to occur in 5 to 44 percent of patients who receive infliximab for psoriasis [].

Perfectil Psoriasis Bewertungen April click the following article, the FDA approved infliximab -dyyb, a biosimilar to infliximab for the treatment of adults with chronic severe plaque psoriasis [ Perfectil Psoriasis Bewertungen, ].

Biosimilar products are approved based upon demonstration of high similarity to an existing biologic drug and absent meaningful differences in safety and efficacy. Adalimumab is approved by the FDA for treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy. Standard dosing for adalimumab for adults is an initial subcutaneous injection of 80 mg of adalimumab followed by 40 mg given every other week, beginning one week after the initial dose.

Examples of studies supporting the efficacy of adalimumab include:. After 12 weeks, more patients treated with adalimumab every other week or weekly achieved at least a 75 percent improvement in the PASI score 53 and 80 percent, respectivelyversus 4 percent with placebo.

In an open label extension of the study, improvements were sustained for 60 weeks. After 16 weeks, disease was cleared or almost cleared in 15 out of 49 patients in the adalimumab group 31 percent compared with 1 out of 23 patients in the placebo group 4 percent.

Adalimumab may be an effective alternative for patients who fail to respond to etanercept [ ]. Treatment success rates approached 50 percent when adalimumab 40 mg weekly or every other week was given for an additional 12 weeks.

Further study is necessary to determine whether assessing serum levels of adalimumab during treatment will be useful for improving responses to therapy [ ]. In Septemberthe FDA approved adalimumab -atto, a biosimilar to adalimumab, for the treatment of adults with moderate to severe chronic plaque psoriasis [ ]. In a randomized trial that compared adalimumab-atto with adalimumab in adults with moderate to severe plaque psoriasis, the two drugs demonstrated similar efficacy and safety after 16 weeks of treatment [ ].

Ustekinumab is indicated for the treatment of adult patients with moderate to severe psoriasis who are candidates for phototherapy or systemic therapy. Dosing of ustekinumab is weight-based. A 90 mg dose given in the same regimen is recommended for adults who weigh more than kg. Phase III trials have confirmed the efficacy of ustekinumab [ ]. Examples of phase III trial data on ustekinumab therapy include:.

Juckreiz Hepatitis was administered monthly by subcutaneous injection for the first two doses and then every 12 weeks. Responders who were kept on therapy generally maintained improvements in psoriasis out to at least 76 weeks.

Serious adverse events were seen at similar rates in the ustekinumab and placebo arms. Patients who achieved a partial response at week 28 Perfectil Psoriasis Bewertungen randomly assigned to continue every 12 week dosing or escalate to every 8 week dosing. More frequent dosing did not enhance response rates at one year in patients receiving 45 mg, but did enhance 75 percent improvement rates in those receiving 90 mg 69 versus 33 percent with continued 12 week dosing. Serious Perfectil Psoriasis Bewertungen events were again seen at similar rates in the ustekinumab and placebo arms.

Trial data on the use of ustekinumab in adolescents with psoriasis are limited. A randomized trial of adolescents ages 12 to 17 years with moderate to severe psoriasis CADMUS found ustekinumab effective in this population [ ].

The response to ustekinumab 0. The efficacy of ustekinumab appears to persist over time. Follow-up data from one of the phase III randomized trials above [ ] demonstrated maintenance of a high level of drug efficacy over the course of three years [ ]. In addition, treatment appears to be well tolerated []. A randomized trial reported superior efficacy of ustekinumab over etanercept for the treatment of psoriasis [ ].

In this trial, patients with moderate to severe psoriasis received 90 mg of ustekinumab at weeks 0 and 4, 45 mg of ustekinumab at weeks 0 and 4, or Sheabutter in der Behandlung von Psoriasis mg of etanercept twice weekly. After 12 weeks, 75 percent improvement in the PASI score was observed in In addition, some patients who did not respond to etanercept benefited from treatment with ustekinumab.

Twelve weeks after crossover to 90 mg of ustekinumab administered at weeks http://gl-dd.de/psoriasis-foto-auf-dem-koerper-der-anfangsphase-des-fotos.php and 20 The incidence of serious adverse effects was similar between Perfectil Psoriasis Bewertungen groups. Data are limited on the best methods for transitioning patients from other therapies to ustekinumab. In a randomized trial TRANSIT trial performed in patients with moderate to severe plaque psoriasis who had insufficient responses to methotrexatemeasures of the efficacy and safety of ustekinumab after 12 weeks were similar among patients who immediately discontinued methotrexate at the start of ustekinumab therapy and patients who gradually withdrew methotrexate during the first four weeks after starting ustekinumab [ ].

Standard doses of ustekinumab were given; patients weighing kg or less and patients weighing more than kg were assigned to 45 and 90 mg doses, respectively. The findings of this study suggest that Perfectil Psoriasis Bewertungen of methotrexate during the transition to ustekinumab treatment may not be necessary. While there are not extensive data on the use of ustekinumab with methotrexate in patients with psoriasis, ustekinumab is FDA approved as a treatment with or without concomitant methotrexate in patients with psoriatic arthritis.

Because of its immunomodulatory mechanism of action, there is concern that ustekinumab may increase the risk for infections and malignancy. However, five-year safety data showed no dose-related or cumulative sign of increased risk of severe infection or malignancy [ ]. Uncommon drug-related adverse effects, such as reversible posterior leukoencephalopathy syndrome and a lymphomatoid drug eruption have occurred in two separate patients [].

See "Reversible posterior leukoencephalopathy syndrome". Although randomized trials have demonstrated efficacy of ustekinumab for psoriatic arthritis, concern has been raised about whether psoriatic arthritis may worsen in certain patients during ustekinumab therapy.

A case series documents four patients with psoriasis in whom Perfectil Psoriasis Bewertungen arthritis flared during ustekinumab therapy [ ]. The meta-analysis found that more major adverse cardiovascular events were reported in patients who received active treatment with ustekinumab or briakinumab than in those who received placebo 10 out of patients versus 0 out of patients.

Although the difference in events was not statistically significant, the trial lengths were short 12 to 20 weeksand Perfectil Psoriasis Bewertungen meta-analysis may have been underpowered to detect a significant difference. A review of pooled data from phase Perfectil Psoriasis Bewertungen and phase III trials with up to five years follow-up did not reveal an increased risk for major adverse cardiovascular events [ ].

In addition, analysis of data from a large observational Perfectil Psoriasis Bewertungen of patients receiving or eligible to receive systemic therapy for psoriasis PSOLAR did not find an association between ustekinumab therapy and major adverse cardiovascular events [ ]. Anti- ustekinumab antibodies have been reported to occur in 4 to 6 percent of patients treated with ustekinumab for psoriasis; however, an effect of anti-ustekinumab antibody formation on treatment efficacy remains to be confirmed [ ].

Standard dosing for plaque psoriasis is mg given subcutaneously once weekly at weeks 0, 1, 2, 3, and 4 followed by mg every four weeks. Doses of mg are sufficient for some patients.

Secukinumab is also effective for psoriatic arthritis. Two week phase III placebo-controlled trials ERASURE trial and FIXTURE trial support the efficacy of secukinumab for moderate to severe plaque psoriasis [ ]. In both trials, secukinumab was given as a mg or mg dose once weekly for five weeks, then once every four weeks. After 12 weeks, a 75 percent reduction in PASI score was detected in 77 percent of patients in the mg secukinumab group, 67 percent of patients in the mg secukinumab group, 44 percent of patients in the etanercept Perfectil Psoriasis Bewertungen, and 5 percent of patients in Perfectil Psoriasis Bewertungen placebo group.

Secukinumab has demonstrated greater efficacy for moderate to severe plaque psoriasis than ustekinumab with a similar degree of safety. In a prospective trial CLEAR trialadults with moderate to severe plaque psoriasis were randomly assigned to secukinumab mg given at baseline, week 1, week 2, and week 3, then every 4 weeks and ustekinumab 45 mg or 90 mg given at baseline, week 4, and then every 12 weeks [ ].

After 16 weeks, 90 percent improvement in PASI score occurred in 79 percent of patients in the secukinumab group compared with 58 percent of patients in the ustekinumab group. The rates of adverse effects were similar in the two groups. An analysis of additional data from the CLEAR trial revealed that with continued treatment, the greater efficacy of secukinumab persists for at least 52 weeks [ ]. At week 52, 76 percent of patients in the secukinumab group achieved at least 90 percent improvement in the PASI score compared with 61 percent in the ustekinumab group.

Safety was comparable between the two groups. Phase III trials support the efficacy of ixekizumab [ ]. Standard dosing for ixekizumab is mg at week 0, followed by 80 mg at weeks 2, 4, 6, 8, 10, and Subsequently, 80 mg are given every four weeks. At week 12, more patients treated with ixekizumab every two weeks or ixekizumab every four weeks achieved PASI 75 than patients treated with etanercept or placebo.

In UNCOVER-2, PASI 75 rates were 90, 78, 42, and 2 percent, respectively. PASI 75 rates in UNCOVER-3 were 87, 84, 53, and 7 percent, respectively. The week induction periods in the UNCOVER trials were followed by week extension periods.

In UNCOVER-1 and UNCOVER-2, patients who responded to ixekizumab at Perfectil Psoriasis Bewertungen 12 Perfectil Psoriasis Bewertungen or minimal psoriasis on static Physician Global Assessment were randomly reassigned to receive 80 mg of ixekizumab every four weeks, 80 mg of ixekizumab every 12 weeks, or placebo. At the week 60 time point, 74, 39, and 7 percent of patients, respectively, still had clear or minimal psoriasis.

Patients in UNCOVER-3 continued ixekizumab at a dose of 80 mg every four weeks after the induction period at the discretion of the investigator and patient.

At week 60, clear or minimal psoriasis rates among patients initially treated with ixekizumab every two weeks and every four weeks were 75 and 73 percent, respectively. The rates of serious adverse effects were similar in the ixekizumab and placebo groups. Overall, neutropenia, candidal infection, and inflammatory bowel disease occurred in 12, 3, and less than 1 percent of all patients exposed to ixekizumab during weeks 0 to 60, respectively.

Neutropenia was generally transient and did not result in cessation of ixekizumab. In Februarythe FDA approved brodalumab for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic http://gl-dd.de/psoriasis-chat.php or phototherapy and have failed Perfectil Psoriasis Bewertungen respond or have lost response to other systemic therapies Perfectil Psoriasis Bewertungen ].

In the United States, the drug will only be available through a Risk Evaluation and Mitigation Strategy program due to concerns regarding risk for suicidal ideation and completed suicides in treated patients. Data from phase III randomized trials support the efficacy of brodalumab for moderate to severe plaque psoriasis []. At week 12, more patients receiving mg of brodalumab or mg of brodalumab achieved PASI 75 compared with patients in the placebo group 86, 67, and 8 percent, respectively [AMAGINE-2], and 85, 69, and 6 percent, respectively [AMAGINE-3].

A statistically significant benefit of the mg dose of brodalumab over ustekinumab for achieving PASI was evident in AMAGINE-3 at week 12 but not in AMAGINE Mild to moderate Candida infections were more frequent in the brodalumab groups than in the ustekinumab and placebo groups, and neutropenia occurred more frequently in the brodalumab and ustekinumab groups than in the placebo group. In addition, two suicides occurred in patients receiving brodalumab in crossover and open-label phases of AMAGINE However, in lateproduction and distribution of alefacept was discontinued by the drug manufacturer [ ].

The discontinuation of production was neither due to new safety concerns nor a mandatory recall. Alefacept was generally considered to be less effective for psoriasis than other biologic therapies. Itolizumab is not available in the United States. The findings of a phase III trial support the superiority of itolizumab compared with placebo for the treatment of moderate to severe plaque psoriasis [ ]. However, response rates in the phase III trial were lower than those reported in phase III trials of infliximabadalimumaband ustekinumab therapy [ ,, ].

The efficacy of itolizumab has not been directly compared with other biologic agents. These drugs include hydroxyurea6-thioguanine, and azathioprinewhich have a place in the treatment of psoriasis when other systemic modalities cannot be used, and tacrolimuswhich is similar to cyclosporine and requires larger studies before it can be considered an accepted alternative [ 81 ].

Daclizumabwhich is used for prevention of renal transplant rejection, and the cancer chemotherapeutic drug paclitaxel are also under investigation for Perfectil Psoriasis Bewertungen in severe psoriasis []. Phosphodiesterase 4 inhibition reduces production of multiple cytokines involved in the pathogenesis of psoriasis.

Apremilast is costly, priced closer to biologics than to methotrexate. Apremilast is indicated for the treatment Sie Solanin Psoriasis Deutsch moderate to severe plaque psoriasis in patients who are candidates for phototherapy or systemic Perfectil Psoriasis Bewertungen. The approval was supported by the findings of two week multicenter randomized trials in which a total adults with moderate to severe psoriasis were randomly assigned to receive 30 mg of apremilast twice daily or Perfectil Psoriasis Bewertungen [ ].

In the first trial, 33 percent of patients treated with apremilast achieved 75 percent improvement in the Psoriasis Area and Severity Index PASIcompared with only 5 percent of patients in the placebo group.

Results of the second trial were similar; 29 percent of Perfectil Psoriasis Bewertungen treated with apremilast achieved PASI, compared with 6 percent of patients in the placebo group.

Although apremilast represents an alternative systemic agent for the treatment of psoriasis, reported treatment success Perfectil Psoriasis Bewertungen with apremilast are lower than those frequently reported for cyclosporineanti-TNF biologic agents, and ustekinumab [ 85 ].

The use of a 30 mg twice daily dose of apremilast is further supported by a phase II randomized trial of adults with moderate to severe plaque psoriasis that found lower efficacy with reduced doses. Among patients treated with 30 mg twice daily, 20 mg twice daily, 10 mg twice daily, and placebo, Perfectil Psoriasis Bewertungen was achieved by 41, 29, 11, and 6 percent of patients, respectively [ ]. Apremilast is associated with a short-term risk of diarrhea, especially when treatment is started, occurring in roughly 15 to 20 percent Psoriasis Garra Fisch Rufa und patients.

Tolerability of apremilast is improved by slowly ramping up the dose when treatment is initiated. The recommended dose titration schedule for adults is as follows:. In adult patients with severe renal impairment the recommended final dose is 30 mg once daily. At the start of therapy, only the Perfectil Psoriasis Bewertungen dose of the above titration schedule is given. Examples of other reported side effects of apremilast include nausea, upper respiratory infection, headache, and weight loss.

Periodic monitoring of weight is recommended [ ]. Advising Perfectil Psoriasis Bewertungen, their caregivers, and families to be alert for worsening depression, suicidal thoughts, or other mood changes during treatment also is suggested based upon the possibility of a slight increase in risk for depression [ ].

A systematic review of randomized trials found evidence to support superior efficacy of fumaric acid esters compared with placebo for psoriasis; however, the quality of the evidence was low overall [ ]. In a randomized trial of Arthritis psoriatischer Inzidenz patients with moderate to severe psoriasis, reductions in disease severity after treatment Perfectil Psoriasis Bewertungen fumaric acid esters were similar to those Perfectil Psoriasis Bewertungen with methotrexate therapy [ ].

Additional trials of fumarates are being performed. Lymphopenia is an occasional side effect of treatment with fumaric acid esters. Intwo cases of progressive multifocal leukoencephalopathy PML Perfectil Psoriasis Bewertungen reported in patients who continued Perfectil Psoriasis Bewertungen receive long-term fumaric acid ester therapy despite the development of severe lymphopenia [].

These patients did not have other known causes of immunodeficiency. Perfectil Psoriasis Bewertungen in the setting of fumaric acid therapy for psoriasis has Perfectil Psoriasis Bewertungen been reported in Perfectil Psoriasis Bewertungen patients without severe lymphocytopenia []. A systematic review that evaluated data on tonsillectomy for guttate or plaque psoriasis from controlled and observational studies including case reports and case series found that the majority of reported patients experienced improvement in psoriasis after tonsillectomy of patients [ ].

Lengthening of psoriasis remissions and improvement in response to treatments for psoriasis were also documented. However, data were insufficient to recommend the routine use of tonsillectomy for psoriasis because most of the patient data were derived from case reports and case series and publication bias may have contributed to the favorable results. Further study is necessary to confirm the effects of tonsillectomy on psoriasis.

Relapse after tonsillectomy is also possible. Because of the potential morbidity associated with tonsillectomy, a method to determine which patients are most likely to benefit from the procedure would be of value. These therapies are designed to mediate psoriasis through a variety of mechanisms. Drugs such as briakinumab [ ] have been developed Perfectil Psoriasis Bewertungen target this pathway.

Marketing plans for briakinumab have been suspended, and it remains uncertain whether the drug will become available for clinical Perfectil Psoriasis Bewertungen. Examples of small molecules that are being Perfectil Psoriasis Bewertungen for the treatment of psoriasis include molecules that block Janus kinases JAK [ ], lipids [ ], and a protein kinase C inhibitor [ ].

Additional phase III trials comparing tofacitinib 10 mg twice daily, tofacitinib 5 mg twice Perfectil Psoriasis Bewertungen, and placebo for chronic plaque psoriasis also have demonstrated efficacy of tofacitinib therapy [ ]. The best results Perfectil Psoriasis Bewertungen achieved with 10 mg twice-daily dosing. The onset of effect of tofacitinib can be fairly rapid, with responses evident by week 4, and there are data to support the efficacy of tofacitinib through two years [ ].

Treatment is generally well tolerated. Tofacitinib may increase risk for infection. Elevations of cholesterol and creatine phosphokinase levels also may occur during therapy [].

In addition, a phase II randomized trial found that a topical formulation of tofacitinib was more effective for plaque psoriasis than vehicle [ ]. In this study, patients were randomly assigned to treatment with daily doses of baricitinib 2, 4, 8, or 10 mg, or placebo. At 12 weeks, more Perfectil Psoriasis Bewertungen in the baricitinib 8 and 10 mg groups than those in the placebo group achieved a 75 percent improvement in the PASI score from baseline 43, 54, and 17 percent, respectively.

Adverse effects were more common among patients receiving the highest baricitinib doses and included infections, lymphopenia, neutropenia, anemia, and elevation Perfectil Psoriasis Bewertungen creatine phosphokinase. Ponesimod, a selective modulator of S1PR1 also studied for the treatment of multiple sclerosis, induces internalization of S1PR1, thereby inhibiting sphingosine 1-phosphate S1P -induced egress of lymphocytes.

In a small randomized trial, a novel formulation of topical cyclosporine using liposomal carriers to improve penetration of the stratum corneum demonstrated efficacy for limited chronic plaque psoriasis [ ].

See "Society guideline links: These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are Perfectil Psoriasis Bewertungen patient education articles that are relevant to this topic.

We encourage you to print or e-mail these topics to your patients. You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest. Psoriasis The Basics ". Psoriasis Beyond the Basics ". The National Perfectil Psoriasis Bewertungen Foundation is a nonprofit organization that provides useful information to patients with psoriasis and their clinicians. Membership includes access to a newsletter that provides information on current areas of research and new treatments.

Brochures on Perfectil Psoriasis Bewertungen forms of psoriasis treatment Perfectil Psoriasis Bewertungen, phototherapy, systemic agents and specific fact sheets on each biologic treatment are available from the Foundation and its website.

Treatment modalities are chosen on the basis of disease severity, relevant comorbidities, patient preference including Perfectil Psoriasis Bewertungen and convenienceefficacy, and evaluation of individual patient response. Alternatives include tar, topical retinoids tazarotenetopical vitamin D, and anthralin. For facial or intertriginous areas, topical tacrolimus or pimecrolimus may be used as alternatives or as corticosteroid Perfectil Psoriasis Bewertungen agents.

Improvement can be anticipated Perfectil Psoriasis Bewertungen one or two months. Combination regimens may be required, including localized phototherapy.

Patient adherence may be the largest barrier to treatment success with topical therapies; early Perfectil Psoriasis Bewertungen one week after starting treatment may improve compliance. In patients with contraindications to phototherapy or who have failed phototherapy, we suggest treatment with a systemic agent Grade 2B. Financial considerations or time constraints may also make systemic therapy preferable to phototherapy for some patients.

Improvement should be observed within weeks. Patients with moderate to severe psoriasis on systemic treatment will generally require care by a dermatologist. All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue. It seems to us that you have your JavaScript turned off on your browser. JavaScript is required in order for our site to behave correctly.

Please enable your JavaScript to continue use our site. Search in your own language:. UpToDate allows you to search in the languages below. Please sein, die Temperatur in Verschlimmerung der Psoriasis können your preference. Topics will continue to be in English. The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment.

Pfizer Pharmaceuticals [Independent research grant to the University of Perfectil Psoriasis Bewertungen Development of patient decision aids ]. Editorial stipends from the Journal of Investigative Dermatology and the Journal of the American Academy of Dermatology. Amgen [Psoriasis Etanercept and brodalumab ]; AbbVie Inc. Abena O Ofori, MD Nothing to disclose. All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: This topic last updated: To minimize adverse effects and maximize compliance, the site Perfectil Psoriasis Bewertungen application needs to be considered in choosing the appropriately potent corticosteroid: Facial and intertriginous areas may be well suited to these treatments, which can allow patients to avoid Perfectil Psoriasis Bewertungen topical corticosteroid use: Inan update to the European S3-Guidelines on the systemic treatment of psoriasis was published [ 84 ] Options for systemic therapy include immunosuppressive or immunomodulatory drugs such as methotrexatecyclosporineapremilast and biologic agents.

Risk factors for hepatotoxicity from methotrexate include [ 91 ]: Examples of studies supporting the efficacy of adalimumab include: Examples of phase III trial data on ustekinumab therapy include: The recommended dose titration schedule for adults is as follows: